S3626 Large Type IV Hiatal Hernia Complicated by Organo-Axial and Mesentero-Axial Gastric Volvulus: A Case Report

Abstract

Introduction: A type IV hiatal hernia is characterized by displacement of the stomach along with other organs into the intrathoracic cavity and is associated with laxity of the peri-gastric ligaments. This condition is extremely rare, accounting for less than 5 percent of all hiatal hernias. Due to mechanical issues, paraoesophageal hernias can lead to serious complications such as gastric volvulus. Depending on the axis of rotation, gastric volvulus can be divided into organo-axial, mesentero-axial or a mixed type of volvulus. This case vignette discusses a rare case of a large type IV hiatal hernia with both organo-axial and mesentero-axial gastric volvulus. Case Description/Methods: A 75-year-old female with past medical history of a large hiatal hernia was referred to GI clinic for intermittent post-prandial and right sided non-exertional chest pain of a few years. She denied any associated shortness of breath, diaphoresis, palpitations, and nausea/vomiting. A subsequent diagnostic esophagogastroduodenoscopy (EGD) revealed a significant anatomic distortion of the stomach with a posteroinferior positioning of the pylorus and a large 10 cm paraoesophageal hernia with associated mucosal erythema, edema, and hematin material. To further characterize the anatomy, an upper GI series demonstrated a large type IV hiatal hernia with an intrathoracic stomach measuring 9.3 cm x 15.8 cm and evidence of both organo-axial and mesentero-axial gastric volvulus. Patient was referred to surgery for gastric detorsion, fixation, and repair of the large paraesophageal hernia. (Figure) Discussion: Gastric volvulus is a rare condition and can develop as a complication of a paraesophageal hernia. Due to fixation of the stomach along the GE junction and pylorus axis, the herniated stomach tends to rotate along this longitudinal axis resulting in an organo-axial volvulus. Less frequently, the stomach can rotate along the transverse axis resulting in a mesentero-axial volvulus. Organo-axial and mesentero-axial volvuli occurring together is extremely rare. Chronic gastric volvulus can present with nonspecific symptoms such as intermittent epigastric discomfort, postprandial fullness, nausea, dysphagia, dyspnea, or chest discomfort. Imaging via upper GI series or cross-sectional imaging are required to make the diagnosis. Chronic gastric volvulus secondary to the hiatal hernia can be managed surgically on a nonemergent basis with detorsion, fixation of the gastric volvulus and repair of the hiatal hernia.Figure 1.: Upper GI Series Demonstrated A Large Type IV Hiatal Hernia with An Intrathoracic Stomach measuring 9.3 cm x 15.8 cm.